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ML202 - Sedgwick Claims Management Services: Grade F

ML202 - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse ML202. Sedgwick incorrectly denied valid medical-legal code as “not considered a valid reimbursable code.” Date of Service: 04/06/2021

MLFS Code(s)

ML202 - Follow-up Medical-Legal Evaluation

MLFS Modifier(s)

96 - Evaluation performed by a Psychiatrist or Psychologist when a psychiatric or psychological evaluation is the primary focus of the medical-legal evaluation

MLFS Grade

F

Claims Administrator

Sedgwick Claims Management Services

Bill Review Vendor

Sedgwick CMS National Bill Review

Employer

Los Angeles Unified School District

EOR Adjustment Reason

561 - According to the state fee schedule, this procedure code is not considered a valid reimbursable code. Please re-submit with a valid code.

Second Review Reason to dispute incorrect reimbursement

Claims administrator incorrectly denied reimbursement. Per CCR §9795, ML202 is valid reimbursable procedure code for a Follow-up Medical-Legal Evaluation by a physician which occurs within eighteen months of the date on which a prior Comprehensive Medical-legal Evaluation was performed by the same physician. Provider conducted a Follow-up Medical-Legal Evaluation at the request of the parties. ML202-96 payment due: $2,632.50. In addition to payment, penalties and interest are now due.


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